Several political parties have pledged to plug shortages of healthcare staff at government hospitals and clinics by training more health workers. They're right to be concerned with understaffing, but are they putting the right solutions on the table? Jesse Copelyn investigates.
As the election approaches, one message seems ubiquitous among opposition parties: there is a severe shortage of health workers at government hospitals and clinics. Manifestoes of the DA, EFF, MK, IFP, ActionSA, UDM, Rise Mzansi and the ACDP all make some reference to the issue or simply state they would increase the number of health workers in the system if they were in power.
But why are so many parties from across the political spectrum pointing to this particular problem, and are they proposing realistic solutions?
Government health facilities are shedding staff
Various sources of data show that public health facilities are indeed heavily understaffed, giving weight to parties' concerns. For instance, in March, the National Health Department revealed that appointments for a number of key clinical posts across the country have not been made. In some of the worst-performing provinces - the Free State, North West and Limpopo - more than 20% of posts for medical officers (i.e. non-specialised doctors) were unfilled.
Additionally, in the North West, almost 2 out of 5 nursing posts were vacant, while half of all positions for psychiatrists were unstaffed. Meanwhile in the Free State, a mere 3 out of 5 posts were filled for physiotherapists and occupational therapists.
These health worker shortages appear to be getting worse. The 2030 Human Resources for Health strategy document, which was published by the National Department of Health, estimated that in 2019, we required about 186 000 primary healthcare workers in the public sector. This would ensure that every person that relies on government services had access to a basket of primary healthcare services that matches the country's needs. Yet at the time, we only had about 115 000, meaning that we were short by about 71 000 workers. And by 2025, that gap was projected to widen to over 87 000. This is because it was assumed that the number of clinical staff would remain the same over time, while the overall population (and thus the number of patients) would increase.
In reality, this actually understates the problem, Dr Donnella Besada, a health economist who was involved in that research, tells Spotlight. Rather than remaining the same, the number of health personnel in the public sector probably will have declined by 2025.
"The workforce is likely to go down over time as a result of the freezing of posts, retirement, illness and death," she explains.
Indeed this was a trend that had already begun in the 2010s when total government spending on health began to stagnate in real terms, and irregular expenditure ballooned. Thus, government health facilities didn't have the money to hire more staff, and between 2012 and 2016, the total number of people employed by provincial health departments actually declined.
The extent of the problem is perhaps most acutely seen in the area of specialist care, as the Human Resources for Health strategy document shows. Take anaesthesiologists - the doctors who put you to sleep before an operation and monitor your vital signs. Researchers estimated that given factors like the age of the population and the types of diseases that are prevalent, South Africa should have about 50 anaesthesiologists for every million people. In the private sector, we're well over the bar, with nearly double that targeted ratio. In government health facilities, however, we're way under, at about 6 anaesthesiologists for every million patients.
Right problem, wrong solution?
Clearly, politicians are onto something when they talk about the need to increase the number of health workers in public hospitals and clinics. But how do parties propose that we do this?
While solutions vary, one of the most common proposals that has been put forward both in party manifestos, and in interview responses to questions by Spotlight, is that we should invest more in training of health workers. For instance, the EFF manifesto states that the party would establish "at least one health care training facility per province and [ensure] that there is no province without a health sciences campus, inclusive of nursing school and medical school [sic]". Similarly, the newly established MK party states that it would "expand the capacity and intake of medical schools".
Manifestoes by ActionSA and RiseMzansi also state that they would train more health workers, while the UDM and ACDP told Spotlight that they would invest more in nursing colleges, along with other measures.
What unites these approaches is the belief that a central reason for understaffing is that we aren't training enough health workers, and we have to find ways of boosting this capacity. However, two senior managers in the public health system that spoke to Spotlight provide a very different take. They argue that the most fundamental reason for understaffing is budgetary - facilities simply cannot afford to appoint more health workers even though there are often qualified people available for hire.
#Vote4Health | Most of South Africa's provincial health departments are facing severe budget constraints.
We asked political parties what they plan to do about it in the new parliament and provincial legislatures: https://t.co/NHBE5QGv3a@MYANC @Our_DA @A_C_D_P @EFFSouthAfrica... pic.twitter.com/mPlkmOSdF3
-- Spotlight (@SpotlightNSP) May 24, 2024
For instance, a former CEO of a public hospital in the Western Cape, who would prefer to remain anonymous, explains to Spotlight that the reason their hospital was unable to plug shortages is simply due to "affordability in terms of the budget received from the national government".
In this context, more campuses and colleges would do little to solve the problem. "[T]oo many training institutions mean that once they graduate there are too few posts for internships or community service", the former CEO says, referring to the positions that medical students must take up at government hospitals and clinics after graduating. He elaborates: "Once [the internship and community service] is done, there are no posts for permanent positions".
All the way on the other side of the country, a senior manager at a government hospital in KwaZulu-Natal, who also wanted to remain anonymous, says much the same. He tells Spotlight that "understaffing has been a problem for some time", and that the shortage of nurses is currently the most significant obstacle. Asked about the causes, he says "financial reasons" are almost always to blame (though he did feel that we needed to train more specialists). He elaborates "this year the budget has been cut compared to last financial year, so [the shortages are] a bit severe now".
MUST READ | We tried to find out what political parties are putting on the table for their particular province. Unfortunately, it seems that while the appetite for power is high, the appetite for serious engagement with health issues is low.
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-- Spotlight (@SpotlightNSP) May 24, 2024
Asked whether more training would solve the shortage of nurses and medical officers, he is doubtful. "[M]any of the already-qualified people were not able to be employed, so training more? I don't think this is a solution... for now the focus should be on employing the unemployed people", he says.
This sentiment is also largely echoed by the National Department of Health, which in April stated that there were over 2 000 unfunded posts for medical doctors in the country. An additional R2.4 billion was needed to fill them, according to the department, which has also been battling accusations from the South African Medical Association that over 800 qualified doctors cannot find work. In response, the department claimed that the majority of them had only just finished their training.
Training capacity has already hit its ceiling
What one might not realise from reading party manifestos is that the country has already substantially boosted the training of doctors over the last decade. As I have previously written for Bhekisisa, it is partially because of this that the public health system is increasingly struggling to absorb new medical graduates entering the system.
For instance, Professor Shabir Madhi, the dean of the health faculty at the University of Witwatersrand (WITS), tells Spotlight that universities began to increase the intake of medical students (i.e. those training to be doctors) some time ago, partly due to state pressure. Over a similar time period, the government expanded the Nelson Mandela Fidel Castro programme, which educates medical students in Cuba. As a result, while there were fewer than 1 500 medical graduates that were available to be placed for internships in 2017, there were over 2 100 in 2024.
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The opposite trends have nonetheless taken place for some other health worker categories. For instance, in 2017, there were over 21 000 student nurses and midwives, and this dropped to below 15 000 in 2022. As Spotlight previously reported, this decline is at least in part due to disruptions related to how nurse training is accredited in South Africa.
According to Madhi, we're still not training enough health workers to meet the needs of the country, but further expanding student intake wouldn't address the current understaffing crisis, as the government is unable to employ the health workers that we're already producing. Instead of training more health science students, he says, the health department needs to focus on "incorporating existing and newly graduating healthcare workers into the public sector".
Additionally, even if we resolved our budgetary problems, there are hard limits on how many more students we can currently train, says Madhi, who laughs off campaign promises about building more medical campuses and scaling up student intake. "[M]ost of the training of health workers takes place outside of the classroom in our healthcare facilities," he says, adding that "there are only so many healthcare facilities that have the right type of personnel to be involved in training, and their ability to absorb more trainee healthcare workers is fairly limited".
While universities have increased the intake of medical students over the years, the ceiling has now been reached, argues Madhi, who notes that the number of trainee doctors that WITS is sending to its academic hospitals is "already exceeding the capacity that they can accommodate". As a result, the university now sends students "to other hospitals which weren't necessarily designed, and are not necessarily equipped or resourced, to undertake training". He notes that these problems don't just apply to trainee doctors, but also "occupational therapists, physiotherapists, oral hygienists and dentists".
Madhi concludes: "Unfortunately, politicians are somewhat naive of what is required to establish training programmes in the health sciences".
